Obstacles and problems of ethical leadership from the perspective of nursing leaders: a qualitative content analysis.

In the nursing profession, leadership plays a significant role in creating motivation and thus enabling nurses to provide high quality care. Ethics is an essential component of leadership qualifications and the ethical leader can help create an ethical atmosphere, offer ethical guidance, and ensure the occupational satisfaction of personnel through prioritizing moralities. However, some issues prevent the implementation of this type of leadership by nursing leaders. The aim of this study was to identify and describe some problems and obstacles in ethical leadership faced by nursing leaders, and to help them achieve more accurate information and broader perspective in this field. The present study was conducted using a qualitative approach and content analysis. A total of 14 nursing managers and educators were selected purposefully, and deep and semi-structured interviews were conducted with them. Content analysis was performed using an inductive approach. Three main categories were obtained after data analysis: ethical, cultural and managerial problems. "Ethical problems" pertain to doubt in ethical actions, ethical conflicts and ethical distress; "cultural problems" include organizational and social culture; and "managerial problems" are connected to organizational and staff-related issues. Nursing leaders put forth various aspects of the problems associated with ethical leadership in the clinical setting. This style of leadership could be promoted by developing suitable programs and providing clear-cut strategies for removing the current obstacles and correcting the organizational structure. This can lead to ethical improvement in nursing leaders and subsequently the nurses.


Introduction
Today, health care organizations are subject to rapid and fundamental changes aimed at enhancing the quality of service, patient satisfaction and productivity (1). Parallel with these changes, nurses face cases such as heavy workload, increased patient awareness, various problems related to staff skills, lack of resources, low occupational and life quality, and workplace violence (2). However, there is the expectation that nurses should treat patients in an ethical manner and put ethics first in their professional performance. Across the world, nurses are guided to use professional codes that emphasize their obligation to respect, protect and defend the fundamental rights of the people involved in nursing and health care (3). One of the most powerful methods to promote ethics in health care and the nursing practice is to role model ethical performance on the managerial level (4). Nurses in formal leadership positions should promote ethics (5), which means they should implement ethical leadership (6), an approach that has attracted much attention in recent years. This style of leadership involves the development of appropriate normal behavior through personal actions and interpersonal interactions, and also promotion of such behaviors in subordinates through bilateral exchanges and strengthening of decisionmaking (7). Ethical leaders must strive to model and support ethical performance (4) and at the same time be sensitive to moral issues and enhance nurse's performance by fostering respect for human dignity; thus, they can play an important role in promoting patient safety (8), increase the capacity to discuss and act upon ethics in daily activities (9), and support the ethical competence of nurses (10). Some studies in this field have indicated that ethical leadership leads to reduced work leave and increased job satisfaction in nurses through decreasing moral distress and creating an ethical milieu (11). Furthermore, this style of leadership boosts confidence in the leader, organizational commitment, and psychological empowerment among the personnel (12). Moreover, it exerts considerable effects on the staff's creativity and their energetic feeling (13). Disappointment and lack of confidence, commitment and motivation are among the side effects of leaders' unethical behavior that influence both patients and organizational efficacy negatively (14). Some studies have demonstrated that the leaders' supportive behavior and confidence in management are essential for stabilizing nursing values. These behaviors include empowering nurses to express their concerns and worries, and providing recommendations for improving their work environment and nursing care (15 -17). The Islamic Republic of Iran is located in the Middle East and enjoys one of the oldest civilizations of the world. It is a developing country with specific ethical values and a population of more than seventy million people. Islam is the formal religion in this country (18), and a combination of Iranian and Islamic cultures form its identity. The religious discipline and cultural beliefs of the Iranian people have entered the health care system and ethical issues are prominent in the patient care protocols (19,20). The nursing manpower in Iran is estimated to exceed 150,000, forming a considerable portion of the health care staff. The Iranian health system, like any other developing country, suffers from limited manpower and financial resources inconsistent with health care requirements (20). Similar to their peers in many other countries, Iranian nurses are dissatisfied with their jobs due to work pressure and shortage of time and resources that prevent them from proper fulfillment of their duties (21). Furthermore, they have been shown to suffer from inappropriate work environment, lack of support, discrimination, conflict, limited opportunities for development, dissatisfaction with work conditions due to heavy workload and unusual work hours, lack of power, and undesirable social status (22). Government policies have resolved nurses' concerns to some extent, including workload and nurse-patient professional issues; however, there is still the need for a solution to increase the quality of care and improve patient safety (20,23). It seems that these problems are imposed by lack of leadership skills in nursing managers. Studies have revealed that task-oriented behaviors are the dominant style of health care leaders and educational systems in Iran (24). Leadership plays a role in creating a culture of care (25), and leadership ethics and confidence in nursing leaders are important components of a healthy work environment culture (6,17,26,27); therefore, this study aimed to identify the barriers that impede the application of ethical leadership in health care settings in Iran. Thus, the authors decided to conduct a qualitative research in this field from the perspective of formal nursing leaders in order to get more detailed information on the nature of the problems and obstacles in ethical nursing leadership.

Method
The present study used conventional qualitative content analysis and purposive sampling to investigate the problems and obstacles of ethical leadership in nursing. Conventional content analysis is usually the preferred method in studies that focus on elucidating a phenomenon. This design is suitable when there are limited numbers of existing theories or sporadic literature on the phenomenon under study. In this case, the researchers avoided the application of presupposed categories and managed to distill the categories from the data. Hence, the categories are manifested through deduction (28).
Seeing that in the qualitative approach, the phenomena must be investigated in their natural context, the hospitals and nursing schools of Tehran, Iran, were selected as the research setting. Among the formal nursing leaders, those with at least 2 years of managerial work experience who wished to participate in the study were chosen. Selection criteria for the educators included experience in teaching ethics, leadership status, and publication of books and articles in the field of leadership and ethics. These individuals possessed deep information and experience related to the subject under study (they were key informants) and could provide the researcher with much information. As decisionmakers in the health care system, clinical leaders and university authorities cannot be separated from each other, and the emergence of ideas on ethics requires the participation of both; therefore, nursing educators were also involved in this research. Moreover, the participating educators had some experience in clinical settings and leadership, and a number of them were occupied in the capacity of formal leaders at the time. This study tried to cover a sample with great variety in age, gender, management level, department, and work experience. To find the more experienced participants with a richer reservoir of data, the initial sample was used, which included nursing educators with a 22-year management experience at various levels of nursing as well as teaching ethics. A total of 14 individual interviews were conducted. Data saturation was achieved after 11 interviews, but an additional three were carried out to reach certainty. As confirmed by research participants, the interviews were held in a quiet room in their workplace at hospitals and colleges. All interviews were conducted by the first author, a female PhD candidate in nursing, and a nursing instructor. She has received the customary training for PhD students to prepare for doctoral dissertations, and has also completed a content analysis workshop. After obtaining the approval and written informed consent from the participants, deep and semistructured interviews were conducted to collect the data. The interviewer began with general questions and proceeded to ask, "Where is the position of ethics in your leadership?" Then, based on the goals of the study, the more detailed questions followed, for instance: "Have you ever been in a situation where you did not do what was ethical despite being aware of it? Please explain." and "What happened that led you to behave like that?" In order to obtain more data and clarify certain issues, some probing questions were also asked, such as: "Can you give us an example? What did you mean by that? Can you explain further?" Individual interviews lasted for 35 to 90 minutes and the participants were then asked to discuss any remaining issues that came to mind. The interviews continued till data saturation was achieved so that no new code of data could be retrieved. In this study, the common points were identified, coded and categorized by using latent content analysis. In this method, the researcher searches for specific concepts and the meaning of all the data within the context, and will then design the structural model that can relate the meaningful classes with similar themes (29). All interviews were recorded on tape and the transcripts were typed, reviewed and coded at the end of each interview. To observe the principle of confidentiality, participants' names were not revealed. Instead, each of them was given a specific number and their important particulars such as age, type of degree, and managerial experience were recorded. Data were analyzed simultaneously and continuously by collecting information. Semantic units were extracted in the form of initial codes or open codes from the interviews. The codes were reread several times and placed in subcategories on the basis of similarity and proportion of the participant expressing the same topic. Next, the subcategories were compared with each other and those with similar characteristics were combined to create wider categories, which were presented once more. Some of the measures taken to enhance data accuracy included prolonged involvement with the topic, confirmation of findings by the participants, and observer reviews. To ensure dependability of the data, in addition to the members of the research team, two experts out of the research team were asked to evaluate the interviews, codings and categories. As regards the conformability of the data, all research steps, including data collection and analysis, observer reviews and the research process were documented on a regular basis. To enhance transferability, the entire process of the research and all the work done in the course of the study were prepared in clear and accurate written form to enable others to track and study population characteristics. This study was approved by the Human Research Ethics Committee of Shahid Beheshti University of Medical Sciences in Tehran, Iran. In the course of the study, permission was obtained from the authorities of hospitals, departments and colleges. The interviewer began by introducing herself and explaining the purpose of the research to the participants, who were then asked to complete the demographic questionnaire and informed consent. Moreover, permission to record the interviews and take notes was obtained from the participants, and confidentiality and subjects' freedom to participate in or withdraw from the research was observed. The participants were also assured that their names will not be revealed under any circumstances. Interview tapes are kept anonymously in a safe place and can be accessed only through codes assigned by the researcher.

Results
There were 14 participants with a mean age of 46 years and an average management experience of 12 years. In terms of managerial level, 3 were supervisors (all matrons), 6 were head nurses, and 5 were nursing educators ( Table 1). Analysis of the handwritten notes on participants' experiences of the problems associated with ethical leadership in nursing resulted in the formation of 73 original codes, which were reduced to 21 after merging similar codes. Eventually, three main categories and 7 subcategories emerged that are presented in Table 2. Major groups included ethical problems, cultural problems and managerial problems.

Cultural problems
In data analysis, cultural problems were abstracted as the second category. Like any other institution, hospitals and health care centers have their own beliefs and norms that determine the way of thinking, behavior and performance of employees within the organization. The beliefs and opinions of organization members reflect those of the society in which they grew up. The nursing leaders in this study noted cases that can be classified as cultural problems, including two subcategories of social culture and organizational culture. A) Social culture: Culture is a model of values, beliefs and attitudes of people in every society, and the culture of any organization, including health care centers, is therefore no exception. Lack of respect for the nursing profession and the negative public image associated with it were among the cases that the participants pointed out. This negative attitude has an impact on the self-confidence and motivation of nurses, including nursing leaders. Leaders with low levels of self-confidence and motivation cannot play their leading and supportive role as may be expected.

Discussion
The findings of the present study were similar to those of other studies on this topic. Three main categories were identified, indicating the participants' perceptions and experiences of ethical leadership barriers and problems in the sociocultural context of the Iranian health care setting. It should be mentioned that all formal nursing leaders in this study showed a kind of positive feeling and interest with respect to this leadership style. This was to be expected as members of the nursing workforce are committed to ethical practice in their profession (6). Ethical problems were among the abstracted categories in this research. Nursing leaders experienced doubt in the ethical act, ethical conflicts and distress in the clinical setting. Other studies with similar findings have also mentioned these issues (30 -33).
The results of this study demonstrated that the unexpected outcomes of ethical behavior could cause nursing leaders to hesitate about performing ethical acts. One issue that is raised in emergence of ethical complaints is that not all criteria used to justify ethical beliefs are fair, as they are affected by the ethical beliefs of a culture or a person (34). In one study, Scott states that identification of a right performance is a challenge to organizational resources. She believes that consideration of others' views, detection of unintended consequences and engaging in continuing education is useful for tackling this challenge (30). Today, ethical conflicts and controversies are inevitable in health care organizations round the globe, and this may lead to ethical distress (35). The study participants had experienced this conflict between the nurses' expectations and needs, their own values and beliefs and those of the organization, and the needs of patients and the personnel. Other studies have shown that in the changing health care environment, ethical leaders encounter three different values, i.e., individual (power, value and respect), professional (patient-centered care) and organizational values (competition, risk-taking and position) (31). Lack of balance between care and management duties may lead to ethical conflict in leaders (32). Nursing managers experience conflicts between individual and organizational ethics, especially when they cannot provide quality care due to organizational constraints (33). The results of this study showed that obstacles such as organizational policies and rules, lack of support from superiors, and lack of sufficient and qualified manpower will weaken leaders' capability to perform ethical acts and create ethical distress. These findings are similar to those of the study by Gaudine and Beaton. Their findings revealed that disagreement with organizational policies over employee discipline, centralized decisions, and lack of ethical resources available to nurses are among the sources of ethical distress in ethical leaders (36). Shirey and Fisher believe that ethical distress arises from role complexity and increased stress, and is a source of psychological stress associated with conflicts experienced by nursing managers (37). However, due to the descriptive and general nature of problems, sources of ethical distress were not specifically investigated in this study. Leadership and management are affected by cultural, social, and economical factors. Cultural problems were one of the categories extracted from the participants' statements. The role of culture in human behavior is one of the most important concepts discussed in behavioral sciences. In the present study, participants considered cultural and professional identity as one of the factors contributing to the promotion of the profession and professional attitude. Positive or negative cultural factors can be seen in any society. For example, negative attitudes towards nurses expressed by the participants can be effective on their self-confidence, authority, professional socialization process and professional identity. These findings are approved by other studies as well (21, 38 -45). The sociocultural context can greatly affect the leadership course and efficacy factors, as well as the approval of leadership features in a specific social culture (46 -48). The assessment and interpretation of leaders' behavior and characteristics are related to various sociocultural backgrounds. The participants experienced improper organizational culture such as an absence of model acceptance, which affected their ethical leadership.
The cultural values of an organization are usually a reflection of the society and the environment in which it belongs. Some other studies have suggested that the organizational culture is correlated with individual and leadership efficacies. The constructive aspects of organizational culture encourage individuals to find a way for selfcorrection and acquiring job satisfaction (49). Similar to this study, Aitamaa et al. referred to organizational and cultural factors such as lack of respect for, and the general negative attitude towards the nursing profession in health care organizations, stating that this culture has a negative impact on nurses' work motivation (39). Moreover, research on leadership points out that an understanding of the organizational culture cultivates the efficacy of leadership (50), and that ethical leadership plays the mediating role in the relationship between the organizational culture and personnel consequences such as satisfaction, extra effort, effectiveness (51). Data analysis confirmed that managerial problems are obstacles for ethical leadership. Issues related to the organization such as lack of power and authority in recruitment, low regard for the nursing staff, shortage of manpower and resources, and specific clinical features were among the cases referred to by the participants. This is not consistent with the findings by Fradd, who emphasizes the important role of nursing mangers in organizational decisionmaking in the scope of nursing (52). Of course, other studies have highlighted the limited power and influence of nursing managers and nurses and lack of their participation in organizational decision-making and inequality of professions in organizations (21,39,42). In this study, participants referred to behaviors on the part of the personnel that disrupted the environment and had an impact on the quality of care, thus challenging ethical leadership. For instance, mistreatment, bullying and behavioral disorders such as defamation were among the cases referred to by the participants. Behaviors such as bullying are quite common in the nursing profession, as has been reported in many studies (53 -57). In a study by Gilbert et al., 86.2 % of nursing managers witnessed bullying by the nurses and 52% of them were victims of bullying (56). Aitamaa et al. also investigated issues common among the staff, for instance lack of cooperation, help and trust, groundless criticism, and noncommitment to group decisions (39). Latent behaviors such as insulting or humiliating others and backbiting are among destructive overt behaviors (58,59). The participants mentioned the difference in attitudes towards the same subject as one cause of these behaviors. This is consistent with the findings by Aitamaa et al. For example, in planning personnel shifts and holidays, some see justice as assignment of various shifts in equal numbers, while others believe in planning shifts by taking into account the wants and life conditions of personnel (39).

Conclusion
This study showed that despite the emphasis on ethical leadership in existing research, there are some barriers and problems in the implementation of this style of leadership. These obstacles have various aspects in ethical, cultural, and managerial domains. Identification of these factors can promote the ethical dimension of leadership. Health care policy makers may utilize the findings of this study to formulate programs and clear-cut strategies to remove these barriers and improve organizational structure and thus promote this style of leadership. Moreover, development of organizational ethical codes for guiding the performance of nursing leaders in confrontation with these problems may be helpful. Ethical leadership is feasible through correction of social and organizational cultures, and securing the public confidence in nursing from organizational and extra-organizational aspects. In conclusion, nursing leaders are required to consider the individual and occupational features and characteristics of personnel when approaching these problems. Discussions about the nursing profession and nursing leaders' conditions can improve the standards in this regard. The leaders themselves play a key role in such discussions and should make their actions clearer and more specific. The findings of this study may help with the development of an instrument for investigating the barriers and problems of ethical leadership in nursing. Further studies are required on ethics in management and research, specifically in the case of each of the obstacles, causes of ethical problems, and their frequency and severity as well as their differences in various levels of management. yleneserP , erele is very limited information about the values, resources and mechanisms to resolve ethical problems, and that could be the basis for future research.